What doctors charge: New data reveals vast disparities

Apr. 16, 2014

Getty Images/iStockphoto

Written by

Donovan Slack

Gannett Washington Bureau

Search 180,000 charges onlineSearch by your doctor’s name, city, specialty or procedure — including office visits by new or established patients — to see the charges submitted to Medicare in 2012 at postcrescent.com.

More

ADVERTISEMENT

WASHINGTON — When it comes to the price of visiting a doctor, location matters in Wisconsin.

If you visit a family care physician for the first time in Eagle River in the northern part of the state, for example, the bill could run as low as $68. The average charge for the same initial visit at a Milwaukee clinic? Possibly as high as $548.

Billing amounts also vary widely within cities, towns and regions of the state, according to data released by the U.S. Department of Health and Human Services for the first time in 35 years showing what providers billed Medicare.

Although they are only for Medicare patients and just a portion of what is billed is actually paid out, the billing records provide a glimpse of what top-line prices typically might be for all patients. And like sticker prices on cars, the billing records offer a way to compare general rates.

That information is more critical than it ever has been. With the growth of high-deductible health insurance plans patients are paying more out-of-pocket, forcing them to shop around for the best deal.

A Gannett Washington Bureau analysis of the data for Wisconsin found that there’s indeed reason to comparison shop. In the northeast, the average charge for initial office visits by Medicare patients to primary care doctors in 2012 ranged from an average of $93 each for doctors at a Holy Family Memorial clinic in Manitowoc to $548 at an Aurora clinic in Marinette.

In theGreen Bay, Appleton and Neenah area, the charges ranged from roughly $100 at Prevea Health Service’s Ashwaubenon Health Center urgent care clinic to more than $300 at a ThedaCare clinic in Appleton and more than $400 at an Aurora BayCare facility in Green Bay.

In central Wisconsin, a pair of doctors at a Riverview Family Clinic in Wisconsin Rapids charged $87 on average, while doctors at Marshfield Clinics in Merrill and Weston charged roughly $335 for a first-time patient.

(Page 2 of 4)

Charges also varied among specialists around the state.

Cardiologists and thoracic surgeons submitted bills that ranged from $3,600 to $36,000 to install stents and $8,500 to $22,000 to repair faulty heart valves. The single highest charge submitted was from a Madison spine surgeon who charged $48,000 to install a pain management device.

A starting point

The American Medical Association, which fought the release of the data for decades, argues the records do not provide enough details for people to make accurate determinations about health care providers.

“This information isn’t going to necessarily allow them to determine ‘Is my doctor good? Is my doctor not so good?’” AMA President Dr. Ardis Dee Hoven said. “There’s no way for them to know how this relates to quality, how it relates to health outcomes and access and all sorts of issues. Raw data simply does not give the correct determination of value.”

Hoven also noted that the accuracy of the data has not been verified with the doctors themselves. In a few cases, Gannett found mistakes in the records. For example, a doctor listed as family care physician is actually a cardiologist, and two procedures listed as office visits were actually inpatient assessments in hospitals.

But even some industry groups say the records at least provide an important jumping-off point for asking more questions, like why are charges high or low, and what’s included in the price?

“This is a rough but necessary first step toward building a transparent health care marketplace,” said Julie Bartels, vice president of national health information at the provider-affiliated ThedaCare Center for Healthcare Value, based in Appleton. “We simply must be cautious and responsible in using this data.”

Many factors affect the rates that providers set, from basic overhead expenses like rent to the mix of patients that a practice has, Wisconsin health care providers say.More Medicare or Medicaid patients might prompt a higher billing rate for other patients since the federal insurance for the poor and elderly only covers a fraction of what providers say it costs to treat them. The average amount Medicare actually paid for the initial office visits in Wisconsin was $75, despite the billed amounts, according to the 2012 data.

(Page 3 of 4)

Another reason for some of the disparate charges, some providers say, is that there are certain fees that hospital-based providers tack on that are not included in the data. That may make their billed rates appear artificially low.

“When you look at these hospital-based providers, and most of our competition are hospital-based providers, they have a revenue stream which this dataset does not reveal to us,” said Dr. Brian Ewert, executive director of Marshfield Clinic. “So that’s part of starting to understand the business model of fee setting.”

Some providers argued that that does not explain the extent of the pricing disparities. For example, at the Holy Family clinic in Manitowoc, administrators said their facility fee typically was about $50. Added to the average office charge of $93, the total is still far shy of the hundreds of dollars charged by some other providers.

Keeping costs down

Chief Medical Officer Dr. Steve Driggers said Holy Family is a faith-based nonprofit that tries to keep costs low by eliminating unnecessary tests, medications and other ancillary costs and focusing on keeping people out of the hospital.

“You still get rewarded unfortunately for what you bill,” he said. “Ultimately, we believe that everyone will move along to this kind of methodology. Right now, we’re probably not doing the brightest thing, businesswise.”

The provider in central Wisconsin who charged the lowest amount, Riverview Family Clinic, is also a nonprofit affiliated with a hospital which allows it to bill a separate facility fee not reflected in the Medicare records.

But administrators there say Riverview has also undertaken an aggressive push to eliminate waste and keep costs low. Spokeswoman Nan Taylor said the organization hired a management specialist who went through, department by department, and streamlined procedures and computerized some processes that had been done on paper.

“We often say to ourselves, ‘If we could put this step on a patient’s bill, would a patient want to pay for it?’ And so that’s what the focus is,” Taylor said.

(Page 4 of 4)

The provider with the highest charges statewide for an office visit by a new patient, Aurora Health Care, declined to comment. Aurora doctors Michael Post in Marinette, Barbara Grzaba-Gracz in Milwaukee, and Scott Fenske in New Berlin all billed $548 on average for initial office visits by Medicare patients in 2012. None returned messages left seeking comment, and Aurora spokesman Adam Beeson asked Gannett to stop trying to contact them.

ThedaCare Physicians Chief Operating Officer Jenny Redman-Schell said the $336 average billing charge in the records could have included additional services besides the visit, such as lab tests or other diagnostic procedures.

“Our 2012 average bill for a new patient in our primary care office is around $262,” she said. Redman-Schell added that the charge for an office visit at ThedaCare’s FastCare urgent clinic in 2012 was $60.

At Prevea Health, Senior Vice President and Chief Financial Officer Lorrie Jacobetti said Prevea is committed to keeping costs down and charges the same amount for patients diagnosed in its urgent care clinics as in a primary care setting.

At Marshfield Clinic, Ewert said it’s important to remember that almost no one pays the list price. He sees challenges ahead as consumers begin to shop around for their own care. In the past, price negotiations occurred almost exclusively between providers and insurance companies.

“And now we’re clearly moving into an era where we’re going to move that discussion to the patient level, where the patient is going to be much more engaged in, ‘What is the price?DoI want to purchase this service myself because I’m going to need to decide this in the context of my family budget?” Ewert said. “This is not my health plan’s problem anymore if I have a $5,000 deductible. This is my problem and I have a heating bill sitting here and I need to decide whether to go get my medical issue addressed.’”

The Wisconsin Health Information Organization, which has conducted dozens of focus groups on patient attitudes across the state, from Green Bay and Appleton to Milwaukee and Madison, discovered that many Wisconsinites focused less on health outcomes and more on convenience -- how long is the wait for an appointment, for example. They also prized interpersonal relationships -- is the doctor likeable, for instance.

“Really. . . they don’t have an understanding of how to differentiate quality,” said Chief Executive Officer Jo Musser, a former Wisconsin insurance commissioner.

She said her organization plans to push three messages to consumers.

“There’s variation in health care, it’s not all equal,” she said. “Choosing a primary care doctor is really an important decision of yours to make, and the third message is, this isn’t a spectator sport, you have a role to play and you need to be engaged.”